Sleep apnea: The monster under the bed

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TORONTO, Ont. — Being healthy isn’t always about hitting the gym, eating a balanced diet, and drinking enough water. There’s one component of health and wellness that is often overlooked and brushed off: sleep.

Sleep is vital to one’s well-being and more often than not, not getting enough sleep can be a nightmare. For some it’s about following a strict routine and getting to bed at a certain hour. For others, sleep apnea is the monster under the bed that keeps them from getting the rest they need.

According to a study conducted by the Federal Motor Carrier Safety Administration (FMCSA) in 2001, obstructive sleep apnea (OSA) affects more than a quarter of commercial truck drivers.

To help combat the issue and bring it back into the spotlight, Northbridge Insurance held a sleep apnea symposium in May titled: Obstructive Sleep Apnea – The Impact on Canadian Trucking & Logistics.

Truck News publisher and editorial director Lou Smyrlis moderated the event and helped the conversation flow as several speakers discussed the impact sleep apnea has from a driver, medical, legal and claims perspective.

Living with sleep apnea

The first speaker was Dave Nawton, risk services specialist for Northbridge Insurance. Nawton was diagnosed with sleep apnea back in 2005 and says he didn’t get treatment until 2007.

“Truthfully, I think I had the symptoms of it long before that but I was in a state of denial,” he said.

Symptoms of sleep apnea can be tricky because, like most conditions, even if you have all the telltale signs, it doesn’t necessarily mean you have it. Symptoms of sleep apnea include loud snoring, choking during sleep as well as feeling exhausted during the day and having to nap on a regular basis.

Nawton explained he would frequently shut the door to his office during the day to nap because that’s what his body needed to make it through the day. He said his work projects were always completed last minute because his focus was never in the right place at the right time. He was constantly craving sleep.

“In 2005 when I was diagnosed with it, the first thing that led to it was my doctor noticed my blood pressure had gotten really high,” said Nawton. “They were treating that with medication and then referred me to get a sleep study because I had a bunch of other symptoms. That sleep study came back as positive but I didn’t want to get treatment at that point. In 2007, it was actually my wife who gave me the ultimatum and truthfully at that point in time, I needed to do it because I was exhausted. I was physically and mentally tired every day. I needed naps in the middle of the afternoon at work just to be able to function. The wife complained about snoring constantly, (I had a) sore throat. It was just lousy, like the quality of life was just bad.”

Nawton explained that refusing treatment when he was first diagnosed was a combination of his denial and his benefits packages at work that didn’t cover the cost of the $3,000 CPAP machine required to treat sleep apnea. Around the same time his wife gave him the ultimatum, his work updated the benefits plan it had for its employees, which then covered 90% of the machine’s cost. Nawton said after he used the machine he saw the results immediately.

“I will always remember the second morning I woke up from treatment,” he said. “The first night I was on the machine, I woke up the next day, I felt about the same. The second day I woke up, it was a Sunday morning and honestly, I felt like I was 19 again. No headaches, no sore throats, energy…Two o’clock in the afternoon comes around and I’m not tired. Then I remember, the Monday going into work and sitting down at my desk and actually having the mental abilities to say, ‘Where am I at? What am I going to get done?’.”

He left the audience with simple advice: if you have any symptoms of sleep apnea or suspect you or a loved one has it, get tested.

“I cannot express enough the wow factor when you wake up after being on the machine and you got a full night’s sleep,” he said. “You’ll be amazed…It’s such a rush because you don’t realize how tired you are until you’ve actually been treated. Once you get that energy back, it’s amazing.”

The medical outlook

Also on the list of speakers were two medical experts – Dr. Geoff Fernie, research director and Dr. Hisham Alshaer, scientist at the Toronto Rehabilitation Institute – who spoke about the medical effects of sleep apnea.

Fernie first explained the definition of sleep apnea saying, “An apneic event is a pause in breathing. When you stop breathing during the night for more than 10 seconds, it’s described as an apneic event.”

Those who stop breathing for more than 10 seconds 10 times per night have obstructive sleep apnea, according to Fernie, who added that the lack of oxygen in the body during these breath pauses cause a spike in blood pressure – and causes even more strain on the patient’s health.

“When the blood pressure goes up, what is happening is that it tends to stay up in the day,” he said. “So you have about four times the chance of being hypertensive, and that’s not a good idea because hypertension also has its consequences.”

Alshaer explained why sleep apnea is so prevalent in the trucking community, according to many American studies.

“Sleep apnea is twice as common in males than females,” he said.“So we are at higher risk and most drivers are males, so this is one factor. Another thing is the lifestyle…prolonged sitting.”

He explained that a “fluid shift” happens when one sits for too long during the day, like at an office desk or behind the steering wheel of a truck. When there is little movement in the legs during a majority of the day, fluid builds up in the legs and when one goes to lie down to sleep, that fluid travels upward into the neck and can cause an obstructed airway, which is sometimes the cause of sleep apnea in adults.

He added diet is a factor as well since obesity is also linked to sleep apnea. Many professional drivers get their meals at truck stops and this has been pointed to as a reason why so many drivers are obese.

“These all add together to aggravate the problem,” he said.

To help make diagnosis less of a production for truck drivers and busy people in general, (going to a sleep clinic overnight and therefore being out of the truck) the doctors showed off Dr. Alshaer’s latest invention, the world’s first portable, cordless medical device for sleep apnea diagnosis.

“What we basically did is to develop a simple thing that you take home and you wear,” explained Fernie. “Just put it on and you just go to sleep. It’s not really a mask. It’s really a frame that’s holding a microphone in there. It’s holding that microphone in front of your mouth and your nose, so it’s able to listen very carefully and record the sounds of your breath.”

By recording the breathing patterns during your sleep the data collected by the machine can be analyzed by doctors who can determine whether or not the patient has sleep apnea.

All things legal

From a legal standpoint, Rui Fernandes, partner at Fernandes & Hearn LLP, explained the obligations fleet owners have to test their drivers for sleep apnea because of the recent guidance the FMCSA issued to medical examiners on how to identify sleep apnea.

“The guidance doesn’t carry any legislative weight,” said Fernandes. “It’s a guide only to doctors, but obviously, people are very concerned that the doctors are going to identify or mis-identify sleep apnea. We are waiting for some formal rule to come forward.”

He explained that if a formal US rule comes out of this guidance and a number of factors are outlined legally to determine that someone has to get tested for sleep apnea, it will affect Canadian truck drivers who travel to the States on a regular basis.

“Canadian standards are going to be affected,” he said. “If you have the five factors that are set out by the US as what is reasonable to test, that’s going to be important into Canada, whether it’s going to be imported through our parliament and legislation or whether it’s just done through the court system when they say, ‘Well, that’s the standard,’ because when we’re looking at negligence and how people determine liability, you’re looking at the reasonable and prudent driver and the reasonable and prudent company.”

Fernandes said that because so many US companies are now testing their drivers for sleep apnea, they are setting a safety standard. He predicted that companies that do not test are going to fall behind and if an accident occurs, they are going to be found negligent by the courts.

“The fact that we don’t have any current legislation that specifically mandates testing is going to be irrelevant because once there’s an accident and they come to your company and you’re being examined and cross-examined…They’re going to say, ‘Well, why didn’t you do any testing?’ The fact that Northbridge is holding a seminar sets a standard. ‘Were you at the Northbridge seminar?’ ‘Oh, yes.’ ‘Did you then institute testing?’ ‘No.’ That’s going to be an impact.”

Peter Aumonier, senior vice-president, claims, national litigation and technical management at Northbridge echoed Fernandes’ perspective and stressed the importance of how being negligent can impact your business.

“In terms of a claim event, there’s nothing new here,” he said. “Again, you’ve all been counseled over the years and run your businesses from a risk management perspective to report claims timely.”

Horan explained to attendees the long process it would take to make sleep apnea testing mandatory or to set a standard on who should be tested.

“On our major regulations that we deal with, generally, it takes a minimum of two years from start to finish,” he said. “That’s the regulation process. You add that 12 to 18 months (to do research) and we’re looking at four years or so before you see a regulation written by FMCSA on obstructive sleep apnea.”

Horan added that with a presidential election coming up, that could also slow things down.

“We’re talking now 2020 before you see anything from us,” he said.

Horan explained the FMCSA’s position on obstructive sleep apnea.

“I think it’s important to know what our position is and has been since about 2000,” he said. “Obstructive sleep apnea is filed basically under one of 13 disqualifying offenses, and…basically our regulation says that you are allowed to drive if you have no condition respiratory-wise that would prevent gradual or sudden incapacitation, which makes perfect sense: you don’t want somebody driving a truck who could suddenly or gradually become incapacitated. I think that position is one that needs to be understood is that is disqualifying. There’s a little line underneath the disqualification. That is, if it’s not treated, people forget about that part. They only hear the OSA and disqualified, and they go crazy. They freak out, ‘Oh, my God! There goes my livelihood.’ That isn’t necessarily true. It’s the untreated obstructive sleep apnea that is disqualifying.”

Horan’s final message to fleets that attended the conference is one that he says he tells drivers in the US all the time: take action now and get tested before legislation comes in effect.

What Canadian fleets are doing

The last speaker of the day was Mark Seymour, CEO of Kriska Transportation, who talked to attendees about his own personal struggles with sleep apnea and how he didn’t wait for legislation to test his own fleet for the condition.

“My personal story really is one that is very similar to David’s,” said Seymour. “For a long time, I would get drowsy in the afternoons, I would wake up most mornings with a dry throat. My wife would be very upset about my snoring all night and how it interrupted her sleep, all those things. It was part of my life and I thought it was just the way it was.”

Seymour says he was never exposed to what sleep apnea was and the treatment available for it until he visited his father in the hospital one day who was asleep with a CPAP machine on his face. After that, Seymour went to his family doctor to get tested and after a sleep study, his test results came back positive: he had sleep apnea, just like his father. He says for the first two yeas of diagnosis he chose not to deal with it out of “sheer embarrassment and shame.”

“A couple of years goes by, for some reason I decided to go back another sleep study and decided to treat it,” he said. “My experience was very positive…I don’t even know what it feels like not to use it anymore because in seven years, I’ve gone two nights without it.”

In January 2011, Seymour decided it was time for Kriska to take action and create a mandatory sleep-testing program for its drivers and employees.

“I personally had my own experience that I could dovetail into why we would do it,” he said of why he began the program. “Since January of 2011, every commercial driver we have hired has had to go through pre-screening. It’s widely been embraced. We have 138 commercial drivers at Kriska today treating obstructive sleep apnea. There’s more. That’s just the number of drivers that we have captured since January 2011.”

Seymour says the program has been widely accepted by everyone at the company because it aligns with the company’s wellness program. He also said he has seen a significant impact on safety.

Seymour explained that during the testing, if one of the drivers is diagnosed with sleep apnea, he or she is treated with a CPAP machine. The clinic will then follow up with the driver four times a year to make sure they are using the machine. However, if drivers are found to be non-compliant, Seymour says there are major consequences.

“They’re parked until they start using their machine again and can prove that,” he said. “I was told yesterday not once, not once since January 2011 have we parked a driver for non-compliance from the sleep clinic. I think it’s evident that people realize that they’re not being made to do something that isn’t helpful and very positive to their quality of life. Again, I cannot tell you how much better one feels by treating OSA. It’s profound. The sleeping and the nodding in the middle of the day, all those things for me went away.”

Seymour says he jumped the gun with sleep apnea testing for his company because he believes legislation is just around corner and wanted to help others who may have been suffering like he had been. He also alluded to the fact drivers who don’t want to be tested for sleep apnea need not apply to his company.

“Mandatory testing for OSA is just another pre-cursor that we think that is coming and we’re ready,” he said. “Much like electronic on-board recorders. It’s part of the fabric of our organization and people have accepted it. If you don’t want to participate in the program, then don’t come and work at our place. It’s just that simple. It’s not a law yet but it’s only a matter of time.”